Provider Demographics
NPI:1417369588
Name:NELSON, CORY (MD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 10TH ST N STE 1E
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1407
Mailing Address - Country:US
Mailing Address - Phone:727-824-3120
Mailing Address - Fax:727-824-8313
Practice Address - Street 1:620 10TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-3120
Practice Address - Fax:727-284-8313
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME125679207Q00000X
FLTRN20293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021753400Medicaid